|
BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG COMMENTS OII'NER AUII,DER D!:I-CARATIoN
<br />I h.ichr" 3lfirn uidcr pcnllry ot tcrjur! rhar I ckm|n itrn rhc Conh.nr' t-i..tra hs td ihd fullosin8 rcr\r ( Scc 70.1 1 5
<br />Burimss , Pi(,rdrshn c{ c): ny Ciry or Counry $hich rcquncs ! IEnnt to con(rucl, rkcr. impto\c. dcnmlth .tr R..nrtr rtry
<br />slNctrtrc- prirlo irs i$unn.c. lko rcquirc\ rhclpplicd nn such Iermn ro filc! \isncd stalc,m rhd heor shc n liccnscd l{nuatrt
<br />ro rhc Pmvi\l.n\ ofrhc Conlrrclors l-iccnsq, Lrw (Chrpl.r 9. Comnrn.inS airh S.di.n 7fllo of Divi\i('n.l orth. Bu\incs and
<br />ProltsionsCodc).rrhdrh.orsh. i\ crcn1pr rhcrclionrrtrd lnc hrst lorlhc rllcscd cicnrfrnr Any!iot.lionolSLrli.nT0ll5hyitrt
<br />rtPli.rnr f(xr pcnnn \uhids rhc trpplicatrrro0.ivilNnrlryofiorDorcrhinfivchrndr.Jdollrh($5Ul)
<br />I, rs owtrcrollhc |n)trny. or my cmployr.r wirh wrtcs is rhcn $b compcns ri{ni. trilldo ih. work md dc {@hft k nor
<br />i cftl{i or oflircd lar slc (Sr 7ol-t. Bu\incs\ nnd Pdt$nn Codcr Th. Contk(ois t-i..n{ tju d..s nor lptly k).n ownfi of
<br />rhcpmlieny who huilds or i.{'r.vcs tlEmn.0 ph dN\ och *lrk hnnscll or hrr*ll or rhnruah hir or hs .wn $]PkDr.s.
<br />proridcd rhar such inpn^urnh d. fr inrc'dcd or ollcrd ri'ruL.l[ ho$err rhc huildin8 or nq,rovcmnr i\ $kl wirhinom Fn
<br />ofcon{lchn. rlf, Owncr Buiklq sill h!!c rhc hunicn oiDnvin8 th hcorsh. dil mr hniltl or irpdc dr pmFdy for rltr N[$s of
<br />-l-
<br />rsowncr orrhc pr.tEdy. r cr.lusivcirc.nhciing wilh lien\cd conn ncn,\ Io con(rucl rtr ll'ojd (Scc 7(r,l-4. Blrncs
<br />aid PFfe$ion(odc:'l he Conlriclois Liccnsc Lnw do.{ tror rtDly k, tri owncr olprcpcny sh. huikk or i'nlo!c\ rh.rcon-
<br />rrd who ..iftids fitr such pnjc.N eirh a Coorrndo( t liccn{d puru ro rhc Corrrrrois Li.cnsc Lrw).
<br />I m,.x.n,I urricr sc.rtrfl . B & tC f(rrhi\ r.rvn,
<br />D.re: Owmr:
<br />woRKFRS' (.()NrPFNSAIiiN
<br />DECLAnAIloti
<br />I h.reby amln!odc! pcnuhyofFrjuryorc ofric ldlosfiE dd.l arn,n\:
<br />_l irvc xl rill minrdn a c.nifi.lrc ot Concnr b Scll lnsure for worksl ompcnsrion. .s pmvidcd for hy Sdion l70o ol rh.
<br />tjbor Codc. for rhc ,.rlortuncc ot rhe *ork ior which lhc p.rnrir ( nsucd
<br />!t U," on,l *ilt ,noin*in *ni ctr comp.Narn)n in\urnncc, ,s rcqltcd hr secr nn .lTlx) or thc tjbor ctdc, ror rhc pcrlorroNc ol
<br />,srrkr i'r\urrm. .r'rlrr rftl |r1li.l tru'nhcrrr.
<br />Ll
<br />--lrIi.cs
<br />l.dn,fyrhrri'rrh.p!rl'o.nrncc.frhcq,orktu{hr.hrhr(p.nnirn$\ucd.Irhallnorrlflk,yrnylcknrin!tr1muncr
<br />so !\ ro hccom suhic.[o rrrc work.( conrpdi\xrn,n hw\ .1 Cil]hrnir aid qrcc n l ir I sh.uld hc.onrc n'U:d b rlr
<br />!o*cr co.rlcsrlfl!r.vnionsolSc.riotr:l7IX)ofrhcl.xhrCodc.lshrll.lanhwiih(ornly*irhrhosr('ei\ion\
<br />wARNIN(;: Frillrc l. sccurc {orkcN compctrr.rn .okrtc is url.wtul. rtrd drll $rhjccr an c yl.yr ro cri'niMl tf,tr lrf,s d
<br />.nil finc\rIi,.nchu rcd rlmusn dolhr\( ll)O.r)(X)) i'r dirn)f t) rlrr .,ar ol co r!.i\arn,n. d!n,gc\ xr ntuvidd ntr rhc
<br />:i:: ikpfi:,rr-n,I
<br />DECI.ABATqN
<br />I hcrcbyrmnnundcr F.ollyolperrury lhet I am lienen utuLr pmvkion olChnrrd 9l..mmking whh seri,n 7000) orDiyiion -l
<br />of lhc Businr$ nnd Potussions Codc. a ,ny li..n* is in lull lorce andcfccr
<br />,""r,.,,", *-E{/4,
<br />g)NIiIBIJCIIOIi.LENUTC.&OEICI
<br />I hcEby smrm under Fnrlry of pcrjury rhd rhcr. h . Nh(flcrion lchdine ascncy rin rhc pcrformncc oi rhc *ork r(r which !hi\ pcmir ii
<br />hsued (Scc. 3097. Ci!. C ).
<br />AIIIICAXLDECI,A.EAIIQN
<br />I h.r..by aflinn undclEnalty ol pcqury oN of lhc lnlh,wina dNhrar bns
<br />Dcmolition Pcrnils-Astrslos Norili.ario6 F.d&rlRcAularions{Tirlc 10- Pan6)
<br />-Rcquircd
<br />trncr orNo ll.dbn
<br />I Rniry rlirr rltr ltl.'rl rcsuhrion\ rc8rtl tr! r!h.no\ rLm*nlIr ior rrrtli.rhl. ki rh \ FN(rZl/l
<br />t-. 14J,cfl
<br />sand Sllrc l-0ws rcl ing to huildiDg.otrifldn,n. and hyrurh.rnc rofrc\cnriivc\ o, ihis
<br />rh,v. trrnrn cd I'otdry ntr i'nFcrion
<br />L a
<br />/\Dplir nl o.]\lMl Si,rn ltrrc
<br />r'"",irm.a-crptnrr: /.t1
<br />Ciry.nd Colnryft, enrcr upon rhc
<br />,.- /r7/rb
<br />Set Backs
<br />UFER Ground
<br />Subf loor/VenVlnsulation r237k [w^ftak {&
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />lr/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Re q
<br />De ut Final R ort
<br />En ineer Final Re rt
<br />Flood Zone Certif .
<br />I /)^,/
<br />FINAL 2fi/eEo Alw&,w
<br />Certificale of Occu pancy
<br />-+
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Rool Sheathinq
<br />Brown Coat
<br />Notes, Remarks, Etc.
<br />r"75013
<br />-f------
<br />I
|